January/February 2017 - Mental Health Insights

January/February 2017

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Mental Health Insights

In This Issue: • • • •

Is Mental Health in a Crisis?

Community Resources Charles Bolles Bolles-Rogers Award Luminary of Twin Cities Medicine

A FAC E O F A M I N N E SOTA DE R M ATOL O GIST Recognized by physicians and nurses as one of the nation’s leading dermatologists, Charles E. Crutchfield III MD has received a significant list of honors including the Karis Humanitarian Award from the Mayo Clinic, 100 Most Influential Health Care Leaders in the State of Minnesota (Minnesota Medicine), and the First a Physician Award from the Minnesota Medical Association, for positively impacting both organized medicine and improving the lives of people in our community. He has a private practice in Eagan and is the team dermatologist for the Minnesota Twins, Wild, Vikings and Timberwolves.

Dr. Crutchfield is a physician, teacher, author, inventor, entrepreneur, and philanthropist. He has several medical patents, has written a children’s book on sun protection, and writes a weekly newspaper health column.

Dr. Crutchfield regularly gives back to the Twin Cities community including sponsoring academic scholarships, camps for children, sponsoring programs for children with dyslexia, mentoring under-represented students from the University of Minnesota, and establishing a Dermatology lectureship at the University of Minnesota. As a professor, he teaches students at both Carleton College and the University of Minnesota Medical School. He lives in Mendota Heights with his wife Laurie, three beautiful children and two hairless cats.

AES

THET I C

L OF APPROVA L SEA

CRU TCHFIELD DERMATOLO GY

CRUTCHFIELD DER MATOLOGY Experience counts. Quality matters.

Mayo Clinic Medical School Graduate | University of Minnesota Dermatology Trained Top Doctor Minneapolis St. Paul Magazine | Best Doctors for Women Minnesota Monthly Magazine

1185 Town Centre Drive, Suite 101, Eagan | 651.209.3600 | www.CrutchfieldDermatology.com

CONTENTS VOLUME 19, NO.1 JANUARY/FEBRUARY 2017

3

IN THIS ISSUE

Addressing Mental Health in the Twin Cities

By Charles G. Terzian, M.D.

4

PRESIDENT’S MESSAGE

Happy New Year!

By Matthew A. Hunt, M.D.

5 6 Page 29

TCMS IN ACTION By Sue Schettle, CEO MENTAL HEALTH

•

Causes and Potential Solutions to Our Crisis in Care For Psychiatric Patients

By Michael Trangle, M.D. and Krist in Dillon, Ph.D.

10

•

Education in the Age of Psychiatry 2.0

By Lora Wichser, M.D. and Kaz Nelson, M.D.

12

•

SPONSORED CONTENT:

Treating Depression in Adolescents

By Prachi Agarwala, M.D.

14

•

The Integrated Health and Wellness Clinic

By L. Read Sulik, M.D., FAAP, DFAACAP

18

•

SPONSORED CONTENT:

The Evolving Care of Patients with Eating Disorders

By Joshua Zimmerman, M.D.

20

•

Greater Mental Health Outcomes Require Coordinated Effort Against Social Stigmas

By Misty Tu, M.D.

22

•

Chances Are

By Sue Abderholden, MPH

24

•

In Mental Health, Talk of Hope and Recovery is Key to Improving Lives

By Shannah C. Mulvihill

26

•

Kicking the Habit: Promoting Tobacco Cessation for People with Mental Illness

By Peter Dehnel, M.D. and Annie Krapek

Page 14

28

•

29

Patrick J. Flynn, M.D. Receives Charles Bolles Bolles-Rogers Award

30 32

MetroDoctors

In Memoriam/Senior Physicians Association LUMINARY OF TWIN CITIES MEDICINE

James J. Jordan, M.D. The Journal of the Twin Cities Medical Society

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Mental Health Insights

Environmental Health — Mental Health Effects of Our Changing Climate

Career Opportunities Page 18

January/February 2017

Page 32

In This Issue:

• Is Mental Health in a Crisis?

• Community Resources • Charles Bolles Bolles-Rogers Award • Luminary of Twin Cities Medicine

A glimpse at the challenges and opportunities when caring for patients with mental illness.

Articles begin on page 6.

January/February 2017

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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Robert R. Neal, Jr., M.D. Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Stephanie Misono, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Medical Student Co-editor Mac Garrett Managing Editor Nancy K. Bauer TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Erica Nelson Cover Design by Emily Larsen

January/February Index to Advertisers

TCMS Officers

President: Carolyn A. McClain, M.D. President-elect: Matthew A. Hunt, M.D. Secretary: Thomas E. Kottke, M.D. Treasurer: Nicholas J. Meyer, M.D. Past President: Kenneth N. Kephart, M.D. TCMS Executive Staff

Sue A. Schettle, Chief Executive Officer (612) 362-3799; sschettle@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com

Crutchfield Dermatology.....................................

Inside Front Cover Entira Family Clinics .......................................30 Fairview Health Services .................................31 Healthcare Billing Resources, Inc. ................. 2 HealthPartners Institute .................................... 9

Karen Peterson, BSN Executive Director, Honoring Choices Minnesota (612) 362-3704; kpeterson@metrodoctors.com

Lakeview Clinic .................................................31

Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com

Saint Therese.......................................................21

MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

Grace Higgins, Project Coordinator, Physician Advocacy Network (612) 362-3706; ghiggins@metrodoctors.com

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS.

Pamela Palan, Project Manager, The Convenings (612) 362-3724; ppalin@metrodoctors.com

M Health ........................... Outside Back Cover

Scott Heiligman Realtor..................................16 St. Cloud VA Medical Center ............................

Inside Back Cover

Annie Krapek, Assistant Project Coordinator, Physician Advocacy Network (612) 362-3715; akrapek@metrodoctors.com

St. David’s Center .............................................23

Helen Nelson, Administrative Assistant, Honoring Choices Minnesota (612) 362-3705; hnelson@metrodoctors.com

U.S. Army Health Care Recruiting .............16

Uptown Dermatology & SkinSpa................28

Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.

For advertising rates and space reservations, contact: Erica Nelson 4084 Jana Ave. NE St. Michael, MN 55376 phone: (763) 497-1778 fax: (763) 497-8810 e-mail: erica@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Andrea Farina at (612) 623-2885.

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January/February 2017

MetroDoctors

The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

Addressing Mental Health in the Twin Cities

T

he theme of this edition of MetroDoctors is Mental Health — a topic that has touched most everyone personally, with our families, friends and/or our patients. It is an important issue for all healthcare systems and is on the agenda of our state and national legislatures. I hope you will agree that we have assembled an excellent mix of articles from a Twins Cities perspective.

I have been fortunate to know several mental health providers and have resources available for my family, friends and patients. I also understand that resources are limited.

As a hospitalist within a major healthcare system, on a daily basis I witness the effects of an inadequate mental health management system despite the fact we have services available. And, not all providers are aware of the programs and services our local community provides. Many mental health service providers are actively responding to improving access by integrating their services with primary care and expanding access to both inpatient and outpatient services.

Drs. Michael Trangle and Kristen Dillon, in their article on Causes and Potential Solutions, present background data on the current situation in caring for psychiatric patients — especially the challenges; they explore causes and provide potential achievable avenues to improve the crisis.

Another article, authored by Misty Tu, M.D., Senior Medical Director of Behavioral Health at BCBS, affirms these challenges and discusses how they ensure quality is instilled into the management and treatment of affected patients they are currently treating. Both Drs. Trangle’s and Tu’s articles have as a common theme the need for more mental health providers.

We then get a look at mental health from the education and training perspective from Drs. Lora Wichser and Kaz Nelson. The University of Minnesota is striving to fill an important need — the training of residents in the field of psychiatry.

As highlighted in many of the articles, not only do we need more providers, but more inpatient beds to

By Charles G. Terzian, M.D. Member, MetroDoctors Editorial Board

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The Journal of the Twin Cities Medical Society

accommodate the care of our patients in need. I recently learned HealthEast system is undertaking an expansion of their inpatient mental health services at St. Joseph’s Hospital aimed at serving an additional 1,500 patients each year. In addition, North Memorial has expanded its Mental Health and Addiction Care program, including an outpatient clinic that opened this past December.

You will also find articles addressing the various approaches to treatment. Sue Abderholden at NAMI Minnesota and Shannah Mulvihill at Mental Health Minnesota outline resources for screening, referral and recovery. Smoking is addressed as a health issue and further explored by Dr. Peter Dehnel and Annie Krapek, representing the work of TCMS Physician Advocacy Network (PAN). Additional management strategies, such as PrairieCare’s Integrated Health and Wellness Clinic, are described by Dr. Read Sulik. We end our overview with articles looking at specific populations: adolescents with whom early intervention is essential. Dr. Prachi Agarwala at the University of Minnesota Health explores some of the impressive data documenting the success in this initiative using both medication and therapy. Dr. Josh Zimmerman offers insight into the population with eating disorders at Melrose Center. Persons with eating disorders present their own unique challenges and we are fortunate to have several options in Minnesota for inpatient and outpatient care.

The TCMS Environmental Health Task Force has contributed an article offering a perspective on how climate change affects mental health issues.

Ending our edition is a fine tribute to James Jordan, M.D., one of our outstanding colleagues who has dedicated his personal and professional life to addressing mental health issues.

January/February 2017

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President’s Message

Happy New Year!

MATTHEW A. HUNT, M.D.

I AM HONORED TO BEGIN MY TERM AS PRESIDENT OF THE TCMS. For those of you I have not met, I am a proud Minnesota transplant, having been here with my family for the past 8 ½ years. I am a neurosurgeon at the University of Minnesota, residency program director, husband and father of two sons. We have embraced Minnesota (and Winter!) and have a hard time imagining living anywhere else. This place is the only home our children have really known and we enjoy everything we have found here. From lakes and cabin life to winter sports to biking, Minnesota is a family paradise!

Speaking for myself, I am glad to put 2016 behind me and move forward into 2017. The past year has been filled with challenges, both large and small. From the turbulent election and natural and manmade disasters, to our daily professional challenges, bouncing back and being positive about the future seems as hard as ever. As our careers advance, the professional challenges seem to grow larger and more difficult to navigate. When I think about the preparation I have had to get to this point in my career, the challenges of biochemistry or anatomy seem distant and less relevant. Instead, the biggest conflicts all revolve around the interactions between ourselves and our peers, colleagues, patients and families. When these interactions go well, they can be incredibly satisfying, even in the most challenging of situations, such as end-of-life discussions, providing feedback to our colleagues and trainees, or seeing our teams perform at their best. Fortunately, with the help of neuroscience, we can stay positive and enjoy change in the face of our everyday challenges.

Keeping the positive mindset seems to be harder and harder when we are overwhelmed with demands on our time (productivity targets), work that challenges our engagement (i.e. EMR), and even the occasional clinical dilemma. It was encouraging to see the recent issue of Minnesota Medicine talk about ways we can stay positive and engaged. It provides an example of how TCMS and our critical partners, including the MMA, support our members. The third plank in our strategic plan is “The Twin Cities is one of the best environments for physicians to live and practice in the nation.” This focus includes providing the resources we need to thrive in our jobs.

However, even with the support of our organizations, much of what we need to do relates to the fundamental neuroscience of change and leadership. In changing ourselves and our organizations, neuroscience dictates how we respond to these challenges. The link between the brain and behavior is becoming better and increasingly understood. Rock and Schwartz (2006)1 lay out many of the challenges and preconceptions that need to be overcome in order for change to happen. First and foremost, they emphasize that the human brain reacts negatively to change. Changes in habits activate some of the primitive areas of our brain and make this uncomfortable.

Second, many of the traditional influence tools we think are effective may not work with the desired effectiveness.

Fortunately, they also lay out the tools we need to change ours and others behaviors: focus, expectation, attention.

Focus means we need to practice the thoughts and behaviors we are trying to cultivate. Expectation is our ability to change how we see the issues that confront us and be able to frame them in ways that help us move forward positively. Attention is the time and energy we need to gain the insight into our problems. Internally generated insight is a stronger motivator and influence than when conclusions are handed to us. Using these lessons from neuroscience, we can positively affect our behavior and change the people and systems around us for the better.

I look forward to serving you and living up to the promise to create an environment for physicians that is one of the best in the nation. Please do not hesitate to reach out to me and the TCMS staff however we can be of assistance.

Reference: 1) http://www.strategy-business.com/article/06207?gko=6da0a

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January/February 2017

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The Journal of the Twin Cities Medical Society

TCMS IN ACTION SUE A. SCHETTLE, CEO

The Convenings: Real Families.

Real Stories. Real Life. Launches With a Bang!

The Convenings is a project directly connected to Honoring Choices Minnesota that engages Minnesotans in conversations about living and dying well. In late November we launched our media partnership with KARE TV. Throughout December and into January 2017, KARE 11 news is airing a series of reports and advertisements on The Convenings. In March a one-hour program will air with a KARE 11 anchor and Cathy Wurzer of MN Public Radio.

This is an exciting project for TCMS to be involved with as our work with Honoring Choices MN has taught us that community-centric support is vital to growing the advance care planning initiative. We are grateful for the opportunity to play this role in The Convenings project.

1st year medical students in public health initiatives. We are working with them on tobacco-related issues including e-cigarettes and menthol cigarettes, as well as end-of-life considerations.

We have also been successful in embedding advance care planning curriculum in the 4th year medical student ICU rotation at the U of M and are having discussions with Mayo Medical School to do the same. Lastly, we are engaging with Special Interest Groups (SIG) at the University of Minnesota on issues related to environmental health. We plan to hold a Lunch ’n Learn in 2017 on the impacts of health care on our environment.

Physician Wellness Discussions Underway

TCMS has entered into discussions with an organization providing services to physicians who are suffering from chemical and alcohol dependency. More information to come.

TCMS to Introduce Legislation in 2017

Volunteers Needed

If you have an interest in joining the TCMS Board of Directors, we have a few openings. We also have openings on the TCMS Foundation Board of Directors, and we are looking for physician volunteers to help bolster the Honoring Choices Minnesota Ambassador program. If you are interested in any of these opportunities please email us at tcms@metrodoctors.com.

Medical Student Engagement

TCMS has developed a relationship with the U of M’s Public Health and Health Policy Program that engages MetroDoctors

TCMS will again be introducing legislation in the 2017 Legislative Session with the goal of obtaining additional resources to support the statewide implementation of advance care planning resources.

We did receive a 20-month appropriation from the 2016 Legislative Session and will be working hard to get that appropriation extended for additional years.

Two Metro Area Physicians Elected to Minnesota Senate

Scott Jensen, M.D. (Republican), a family physician working in Chaska and 2016 Family Physician of the Year, was elected as Senator representing District 47 (Carver County). And, Matt Klein, M.D. (Democrat), a hospitalist at HCMC, representing District 52 (Dakota County), was elected Senator.

Congratulations!

The Journal of the Twin Cities Medical Society

Looking for Another Fantastic Idea!

Do you have an idea that you think would benefit you or your patients that you want to bring forward but you don’t know where to go? We are interested in hearing from you! Honoring Choices MN started because one physician thought it might be a good idea. He brought it to TCMS leadership and we built the program into a national model.

We have done the same with physicianled tobacco control efforts. We want another fantastic idea! Send us your thoughts to tcms@metrodoctors.com.

Welcome Grace Higgins

Grace Higgins, MPH, joined TCMS staff in November as Project Coordinator for the Physician Advocacy Network (PAN). Her responsibilities include educating and engaging physicians in local policy discussions about the dangers of e-cigarettes and flavored tobacco products, especially among youth and communities of color. Grace can be reached at (612) 362-3706; ghiggins@ metrodoctors.com.

Senior Physicians Association to Meet in February

A winter meeting of the Senior Physicians Association will be held on Tuesday, February 21, 2017. See details on page 30.

January/February 2017

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Mental Health

Causes and Potential Solutions to Our Crisis in Care For Psychiatric Patients

I

deally, behavioral health patients have adequate access to the panoply of clinicians and resources to meet most of their needs. Then only a small subset needs to receive crisis services, and fewer still need to go to an emergency department or inpatient unit. However, over time, we have found that inadequate resources and limited access at each level of care in Minnesota are driving more patients to the next higher level of care.

In fall 2006, a three-month study of all seven metro hospitals with inpatient psychiatric units, county social service leaders and the Minnesota Department of Human Services (DHS) highlighted the most frequent causes of higher levels of care (note: not an all-inclusive list): • 40 to 50 patients per month were admitted to inpatient psychiatric units whose needs could have been met by less intensive resources, but these resources were unavailable (35.3% due to lack of adequate nursing home resources to deal with behavioral issues or intensive rehabilitative treatment services; 23% due to lack of detoxification, places for inebriated patients to recover and residential and chemical dependency programs able to handle both mental health and chemical dependency issues; and 10% due to a lack of access to psychotropic medication prescribers).

By Michael Trangle, M.D. and Kristin Dillon, Ph.D.

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January/February 2017

Michael Trangle, M.D.









Kristin Dillon, Ph.D.

Although 240 to 250 patients on inpatient psychiatric units each month could not return home safely, they could have gone to a facility offering less intensive services. This led to 2,000 to 2,100 non-acute potentially avoidable days on an inpatient psychiatric unit.

29.6% of non-acute bed days were associated with unavailable beds at Anoka Metro Regional Treatment Center, a state psychiatric hospital.

22.4% of non-acute bed days were associated with a lack of intensive residential treatment beds.

15% of non-acute bed days were related to court delays.



8.5% of non-acute bed days were attributed to a lack of chemical dependency programs with lodging, the need for a Rule 25 assessment, unavailability of sober beds and the need for detoxification.  8.3% of non-acute bed days were due to needing 24-hour skilled medical/behavioral nursing services, which consist of a combination of open and locked environments.

Since then, the situation has worsened. Most Minnesota psychiatrists are reaching an advanced age, shrinking their practices and retiring. In addition, current residency programs are not producing enough graduates to replace those retiring, let alone to meet the increasing

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needs of a growing population.1 The median age of all actively licensed Minnesota psychiatrists in November 2015 was 55. (Note: median age of all physicians in 2015 was 50).2 Since 2006, the population has grown, while state and county mental health budgets have shrunk, leading to a decrease in state inpatient psychiatric beds and intermediate services.

In 2016, a statewide Minnesota Hospital Association study found that 19% of inpatient bed days were filled with patients waiting for intermediate resources. The most common issues are listed in the table below.3 In the East Metro counties of Ramsey, Dakota and Washington, we were able to drill down and conservatively estimate their need for beds. This showed that these counties need at least 32 Anoka Metro Regional Treatment Center beds, 26 intensive residential treatment services beds, 24 chemical dependency and mental health/chemical dependency beds, and an indeterminate greater number of flexible beds with mental health supports.

When considering evidence-based yet practical solutions that have been successfully used elsewhere, we should look at: • increasing the supply of psychiatrists; • increasing support for psychiatric residencies, loan forgiveness and more residency spots in Minnesota; • increasing the supply of adequately trained advanced practice prescribers (physician assistants, nurse practitioners and clinical nurse specialists). A large percentage of recent graduates from many of these programs do not get adequate psychiatric experience and need substantial further training, which often consists of either short-term mini fellowships (6 months) or protracted mentoring and on-the-job training;  leveraging psychiatric expertise via new models of care such as the Collaborative Care Model MetroDoctors

•

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is based in primary care, where a dedicated care manager who gets direction from a psychiatrist to educate patients on mental health issues, engage them in key lifestyle changes and behavioral activation, ensure they do not get lost in followup, troubleshoot issues along the way and make medication recommendations.

Progress and outcomes are measured, and treatments are modified as circumstances require.  in the Shared Care Model, psychiatrists and psychotherapists advise primary care physicians on treatments; provide consultation; see patients, stabilize them and send them back to primary care for their ongoing care; and, if psychiatric issues re-emerge, patients return to psychiatry to be stabilized and then to primary care for ongoing care.4 televideo medicine is increasingly used to help patients in greater Minnesota overcome geographic issues

•

•

Reason

and regional shortages and to tap into a pool of psychiatrists in other states who can help meet shortages in Minnesota; the Mental Health Drug Assistance Program has consistently shown since 2008 that providing temporary access to psychiatric medications, copays and deductibles in the East Metro has decreased the percentage of patients who are re-hospitalized, go to detox or jail, are homeless or have suicidal thoughts compared with before they were in this program. About 10 percent of participants use this program because they cannot afford copays, deductibles or co-insurance or need help navigating the Medicare “donut hole.” Of the 90% of participants using the program because they have no insurance, roughly 79% who work with a health navigator leave the program with insurance and can sustainably continue to get their medications; an East Metro Mental Health Crisis Alliance study showed that (Continued on page 8)

Number of days

State psychiatric hospital bed unavailable at a Community Behavioral Health Hospital (CBHH) Chemical dependency treatment bed not available Intensive Residential Treatment Services (IRTS) bed not available

836 681 639

Percent of Potentially Avoidable Days

14 11 10

Delay due to patient legal involvement, including civil commitment

476

8

State psychiatric hospital bed unavailable at Anoka Metro Regional Treatment Center (AMRTC)

445

7

Group home bed not available

424

7

Awaiting Community Access for Disability Inclusion (CADI) Waiver approval

343

6

Waiting for a social service or government agency to identify an IRTS placement

338

6

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Mental Health Our Crisis in Care for Psychiatric Patients (Continued from page 7)

•

•

•

•

•

8

providing a psychiatric prescriber as part of a crisis stabilization team significantly decreases inpatient psychiatric usage by 46%, inpatient medical usage by 33% and emergency department usage by 23% and had a return on investment of 2.16;5 data from the East Metro Adult Mental Health Urgent Care showed that when patients see a crisis social worker, about 18% of them do so instead of visiting an emergency department. When they see a prescriber, roughly one-third (31%) of them do so rather than visiting an emergency department;6 create a coalition to convince legislators and DHS to increase state hospital beds to begin to meet the needs of committed patients based on their clinical needs instead of the vagaries of whether they are referred from jails or certain counties (the East Metro alone needs 32 more beds); simplify and streamline the process to create new intensive residential treatment services (IRTS) and other flexible beds with mental health supports. This will require counties, DHS, and private providers to work together. The East Metro alone needs 26 more IRTS beds, and we are still trying to quantify the needed flexible beds with mental health supports; for the East Metro, 24 more chemical dependency and mental health/ chemical dependency beds are needed to meet the needs of patients with severe chemical dependency and mental health needs; in other regions of the state, data from the Minnesota Hospital Association study need to be further analyzed so that the exact number of similar resources can be quantified and built.

January/February 2017

The Governor’s Mental Health Task Force recently released a report that is congruent and aligned with many of these proposed solutions. Like that group, we have avoided the simplistic myth that there is a silver bullet that involves either adding more outpatient- or intermediate-level resources or more inpatient psychiatric beds. The real-world data requires us to build a lot more outpatient and intermediate resources while at the same time adding inpatient beds to meet the current need.

If we see the need for inpatient beds decline, we can and should shrink the pool.

Future needs also require us to expand the pool of psychiatrists and advanced psychiatric prescribers, and increasingly use shared care, collaborative care, and televideo medicine. We have made an effort to use Minnesota data to make these recommendations as detailed and quantified as possible. Many of them could be implemented in the next year or two if we have the political will and make them fiscal priorities.

What Can You Do? If you are moved to take action and help catalyze change: • Get engaged in community groups addressing access for crisis, inpatient, and other community-based services. Be a spokesperson for your patients and persons needing care.

• Encourage your legislator to support approaches that improve access to care, including making it easier to create community residential programs and using the state operated services resources effectively.

• Support efforts to better support and grow psychiatric medical residencies and psychiatric fellowships for physician assistants, nurse practitioners, and clinical nurse specialists in Minnesota.

Michael A. Trangle, M.D., is the Senior Medical Director responsible for the delivery of behavioral health care at Regions

Hospital and within the HealthPartners Medical Group. In his 32 years in the field he has served in a wide range of leadership roles from starting and serving as the Medical Director for Fairview Ridges Chemical Dependency Programs to creating both an inpatient and an outpatient system of care as Executive Medical Director for Allina Health. He has also been an active leader in regional quality improvement initiatives.

Dr. Trangle attended Cornell University as an undergraduate, University of Minnesota, Minneapolis for medical school and was a resident and Chief Resident at the University of Wisconsin in Madison.

Kristin Dillon, Ph.D., is a Research Scientist with Wilder Research, a division of the Amherst H. Wilder Foundation. Kristin has over a decade of experience conducting research and evaluation, including a specialization in adult mental health and substance misuse prevention and recovery. Dr. Dillon has a doctorate in Family Social Science from the University of Minnesota.

References 1.

Minnesota’s Psychiatric Workforce, 2012. Minnesota Department of Health Office of Rural Health and Primary Care. http://www.health. state.mn.us/divs/orhpc/pubs/workforce/psychfact.pdf. Published 2013. Accessed November 1, 2016.

2.

Minnesota Physician Workforce, 2015. Minnesota Department of Health. http://www. health.state.mn.us/divs/orhpc/workforce/ phy/2016phy.pdf. Published 2016. Accessed November 1, 2016.

3.

Dillon K, Thomsen D. Reasons for delays in hospital discharges of behavioral health patients: Results from the Minnesota Hospital Association Mental and Behavioral Health Data Collection Pilot. St. Paul, MN: Wilder Research. http:// www.mnhospitals.org/Portals/0/Documents/ policy-advocacy/mental-health/MHA%20Mental%20Health%20Avoidable%20Days%20 Study%20Report%20July%202016.pdf. Published 2016. Accessed November 1, 2016.

4.

Unützer J, Katon WJ, Fan MY, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care 2008;14(2):95100.

5.

Leite Bennett A, Diaz J. Crisis stabilization claims analysis: Technical report. St. Paul, MN: Wilder Research. https://www.wilder.org/ Wilder-Research/Publications/Studies/Mental%20Health%20Crisis%20Alliance/Crisis%20 Stabilization%20Claims%20Analysis%20-%20 Technical%20Report.pdf. Published 2013. Accessed November 1, 2016.

6.

Dillon K, Thomsen D. Community metrics: 2016 summary statistics January through June. 2016.

St. Paul, MN: Wilder Research.

MetroDoctors

The Journal of the Twin Cities Medical Society

The road to life-changing eating disorder treatments Eating disorders are the most lethal of all psychiatric conditions.

Clinicians at Melrose Center and researchers at HealthPartners Institute are partnering closely to improve clinical outcomes, including refeeding protocols that have doubled the rate of weight restoration.

HealthPartners Institute is one of the largest medical research and education centers in the Midwest.

As part of an integraged health care organization that includes hospitals, clinics and a health plan, our teams are helping transform health care across the nation.

450+ MELROSE CENTER Josh Zimmerman, MD Senior Medical Director of Behavioral Health Heather Gallivan, PsyD, LP Clinical Director

ACTIVE RESEARCH STUDIES EACH YEAR

Mental Health

Education in the Age of Psychiatry 2.0

A

day in the life of a psychiatry resident is not what it used to be. Things are just different.

The rapidly evolving healthcare and societal landscape is reflected by the many changes to the standards and practices within graduate medical education. In the past 10 years, psychiatry residencies have adapted to accrediting requirement changes, such as restrictions in duty hours and increased attention to resident health and wellbeing. The 36-hour shifts are gone.

Training programs have encountered a new generation of physicians with high hopes and expectations for the quality and fulfillment of their residency training and their personal lives outside of the hospital.

The message is clear: we need to be taking better care of our residents. These changes in residency training have occurred in the context of increasing societal attention to high-quality affordable care, increasing demand for psychiatric services, and a patient population equipped with readily accessible information online from both poor- and high-quality sources. Altogether, this creates a formidable challenge.

And yet, there is excitement in the air as the University of Minnesota Department of Psychiatry is poised to address these challenges and opportunities head on. On August 1, 2016, we welcomed Dr. Sophia Vinogradov to our head office. Dr. Vinogradov has brought a renewed vision encompassing excellent patient care, education, and innovative research that drives forward our knowledge of the immensely complex human mind. Put simply — she

By Lora Wichser, M.D. and Kaz Nelson, M.D.

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January/February 2017

Dr. Kaz Nelson, Psychiatry Program Director, and Dr. Lora Wichser, Chief Resident in Psychiatry.

will lead us to achieve Psychiatry 2.0. Dr. Vinogradov seeks to establish the reputation of the Department of Psychiatry as the premier institution globally for discovery across multiple realms. Our investigators’ projects span the exploration of the neural underpinnings of adolescents who self-harm, further development of new and different approaches to schizophrenia treatment, and evaluating learner outcomes for innovative curricula. Ultimately, we seek to share and disseminate this knowledge through world-class psychiatric education. You can see why we’re excited.

As part of this, our residency training is pushing forward in a few key ways.

Leadership

We are developing national leaders. Over the past five years, three of our residents have been awarded American Psychiatric Association (APA) Leadership Fellowships.

This highly prestigious award is presented to 10-12 people nationally each year. APA fellows are embedded within national and global initiatives in psychiatry through direct involvement and mentorship.

Multiple rich opportunities have paved the way for this achievement. The University of Minnesota Graduate Medical Education Office has launched its third cohort of the Resident Leadership Academy — a year-long experience for residents selected for their leadership potential. Our program has enlisted two residents in each cohort, creating a legacy of formally trained leaders enacting change within our department and institution. Additionally, the Minnesota Psychiatric Society has brought together trainees from our program, along with residents from the Hennepin County Medical Center/Regions Hospital and the Mayo Clinic Psychiatry residencies, for the Resident Caucus. This Caucus provides a voice for residents and a chance to collaborate and provide legislative advocacy for our field and the patients we serve. This cross-program collaboration encourages further individual and community growth.

Residents learn from one another.

Psychiatry “Pipeline” Development

More and more Minnesota medical students are choosing psychiatry. The deciding factor? Many students cite exposure to outstanding residents and meaningful clinical experiences. Our residents embrace the role of teacher. They teach on the hospital wards and as presenters of formal didactics on depression, anxiety, and other topics. Residents are engaged in the creation of online learning modules to disseminate to learners across the country at other programs. We have created a curriculum on teaching residents to be teachers. Our residents are encouraged to embrace teaching as a scholarly pursuit and

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share this content broadly to inspire subsequent generations of medical students.

Integrated Care

The high demand and lack of access to mental health services is painfully clear.

Embedding psychiatric expertise in primary care clinics is one way to address this need. Our residents have been learning this model in multiple settings: Smiley’s Primary Care Clinic, the Fairview Integrated Primary Care Clinic and the Minneapolis Veterans Affairs Healthcare Center. Dr. Deanna Bass has created a comprehensive curriculum on this topic, including a unique approach to the abbreviated psychiatric interview for primary care providers. Dr. Bass also incorporates tools into the electronic medical record which serve in a supportive role as a “virtual mentor.”

Robust Psychotherapy Training

Psychiatry residents seek in-depth education and supervision in the practice of psychiatry, which includes robust training in psychotherapeutic modalities. Our residents learn firsthand through supervised practice of supportive psychotherapy, psychodynamic psychotherapy, motivational interviewing and cognitive behavioral therapy (CBT). We are also one of a handful of residency programs across the nation to offer supervised practice experiences in dialectical behavior therapy (DBT), a specialized therapy for patients with high risk of suicide and hospitalization. Residents are also formally trained in family therapy and group therapy. Equipped with mastery of these treatments, residents feel prepared to address the varying needs of their patients. Our partnership with the Minneapolis Veterans Affairs Healthcare Center allows residents the choice of dozens of supervised elective experiences in additional psychotherapeutic modalities.

Resident Wellness and Prevention of Burnout

Issues related to resident wellbeing must go beyond limiting the length of their shift or work week. Residency training has consistently been associated with higher rates of depression, anxiety and burnout. Programs must take steps to support residents and MetroDoctors

mitigate burnout in order to produce physicians who have the capacity for empathy, compassion and patientcentered care. Our program has taken direct steps to create a culture that values wellness and teamwork.

Residents have been integrated into standing departmental committees, which increases their representation, connectedness, and influence on departmental decisions and initiatives.

We have created postvention procedures for resident support following patient death or a significant life event. We have incorporated resident retreats into our academic year. These retreats are a time for the residents to reflect on their journey and set goals for the year ahead. We use mindfulnessbased strategies during meetings to foster resilience, support one another, and build teamwork. Residents have access to physical fitness equipment and space to rest and congregate. Our residents report greater satisfaction with their work and an increased sense of wellbeing.

Inclusive Definitions of Scholarly Work

The stress associated with residency training could discourage resident engagement in research and other academic activities beyond direct patient care. The resident wellness initiative has had the added benefit of fostering residents’ curiosity and motivation to lead broader initiatives such as curriculum development, patient quality and safety methodology, mentorship, teaching, and interdisciplinary collaboration. By including these activities under the umbrella of “academic work” residents are able to approach these projects in a scholarly manner and contribute to the peer-reviewed literature. We continue to encourage participation in more traditionally defined research with the understanding that other forms of scholarly work are also valued.

Our four-year program has been in existence for 64 years and consists of seven residents per class. Our residents rotate primarily at the University of Minnesota as well as the Minneapolis Veterans Affairs

The Journal of the Twin Cities Medical Society

Members of the third year psychiatry residency class participating in a teambuilding retreat. Back row: Chiamaka Nwankiti, M.D., Michael Jose, M.D., Laura Pientka, D.O. Front Row: Carly Dirlam, M.D., Katie Thorsness, M.D., Anna Donoghue, M.D., and Lindsay Merriman, M.D.

Healthcare Center. Training also takes place at community-based sites, including the Community University Health Care Center (CUHCC) and a Guild assertive community treatment (ACT) team. The fourth year of training is almost entirely an opportunity for senior residents to pursue elective rotations in preparation for their practice of choice.

Psychiatry 2.0 has arrived. The University of Minnesota is proud to be at the frontier of mental health care and education.

Lora Wichser, M.D., is a fourth year psychiatry resident, currently serving as chief resident in the University of Minnesota Psychiatry Residency. Dr. Wichser completed undergraduate training in German Studies and Physiology at the University of MinnesotaTwin Cities, and graduated from the University of Minnesota Medical School.

Kaz Nelson, M.D., is certified in psychiatry by the American Board of Psychiatry and Neurology and serves as Vice Chair for Education and Program Director of the Psychiatry Residency in the Department of Psychiatry at the University of Minnesota.

Dr. Nelson received her medical degree and psychiatry residency training from the University of Minnesota Medical School.

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Sponsored Content

Treating Depression in Adolescents Contributed by Prachi Agarwala, M.D.

D

epression is a complex disease that has major public health and economic implications. Major depressive disorder is the primary diagnosis in an average of 8 million patient visits a year to primary care offices and emergency departments.1 According to the Centers for Disease Control (CDC), 7.6% of persons 12 years of age or older suffer from depression in any given 2 week period.2 In 2000, the total economic burden of depression was estimated at $83 billion,3 approximately 60% of this cost representing loss in workplace productivity. When the cost of lost work days is compared, the economic burden of depression was found to be the same or greater than that of heart disease or diabetes.4 In addition to the emotional toll that suicide has on surviving loved ones, completed suicides and suicide attempts also have economic costs.

When considering medical costs and lost productivity, the average cost per year of one suicide is calculated to be $1,795,379, with the majority of this amount coming from lost productivity.5 Depressive and other mood disorders frequently emerge in adolescence, a period of critical social and emotional development.6 Antidepressant medication is prescribed to 3.2% of the adolescent population.7 Major depressive disorder in this population can manifest itself in suicidal thoughts and behaviors — common signs of the disorder. A 2013 national survey conducted by the CDC found that 17% of high school students seriously considered attempting suicide within the past year. Eight percent of high school students

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January/February 2017

went on to attempt suicide one or more times, with almost 3% requiring medical attention following their attempt.8 Suicide is the third leading cause of death among adolescents 10 to 14 years of age and the second leading cause among adolescents 15 to 19 years of age.9 Depression has clear impacts on adolescent health. Fortunately, current clinical practices can provide effective treatment for many youth diagnosed with major depressive disorder, and new and experimental therapies are emerging that hold promise as approaches to managing treatment-resistant disorders.

Current Treatment Approaches

Research supports both pharmacological and nonpharmacological approaches

or a combination of both for treating depression. The Treatment for Adolescents with Depression Study (TADS)10 and Treatment of Resistant Depression in Adolescents (TORDIA)11 studies have demonstrated the benefits of medication and therapy in addressing depressive disorders in the adolescent population. The most common medications prescribed for depression in adolescents are the selective serotonin reuptake inhibitors (SSRIs).

This class includes fluoxetine (Prozac), sertraline (Zoloft), and others. Medication typically provides benefit within 4 to 8 weeks of starting the prescription. SSRI’s do have an FDA-issued black box warning regarding the potential risk they pose of increased suicidal thoughts or behaviors; therefore, patients should be monitored while starting and taking the medication.

Cognitive behavioral therapy (CBT) is an evidence-based therapeutic approach to treating depression and has been demonstrated to be a mediating factor in reducing suicidal thoughts and behaviors. Based on the premise that thoughts, behaviors, and emotions are interconnected and that modifying patterns in one area will affect the others, CBT typically focuses on identifying and restructuring negative thoughts, increasing pleasurable behaviors (activation), and increasing social and problem-solving skills. It is typically conducted over 8 to 12 weekly sessions, with some maintenance sessions in the weeks after the initial phase of therapy.

The majority of adolescents struggling with depression are treated in primary care clinics by pediatric and family practice

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providers and by therapists in the community. In adolescents with increasingly severe or resistant-to-treatment depressive symptoms, psychiatric involvement is often indicated. More intensive interventions are necessary when suicidal thoughts emerge or become more frequent.

Several levels of care are available at University of Minnesota Medical Center for adolescents struggling with depression and suicidal thoughts. These range from outpatient psychiatry and therapy services to partial hospitalization programs to inpatient hospitalization.

Partial hospitalization programs take place over 3 to 5 weeks and provide more intensive group therapy and medication management. Programming occurs during the school day. In addition to therapeutic work, patients engage with Minneapolis teachers to complete school assignments in order to prevent delays in their education.

Inpatient hospitalization allows for more intensive crisis stabilization for patients with more acute need for care. Patients in both partial and inpatient hospitalization programs are offered a wide array of treatment modalities, including psychotropic medication and skill training on managing distress and frustration. Additionally, clinical rehabilitation therapists work with patients on sensory needs, music therapy, social skills, and exercise/movement techniques.

Research into New Therapies

The Department of Psychiatry at the University of Minnesota is currently engaged in several trials to demonstrate what physiological changes occur in the brain when patients have depressive disorders and/or self-harm behaviors and to assess more novel treatment strategies for depression in the adolescent population. Using a combination of neuroimaging, endocrine labs, biomarkers and observation, University of Minnesota researchers are

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studying how adolescents with depression process environmental data and modulate their emotional state based on this data. In another study, research teams are assessing the efficacy of intravenous ketamine as a drug therapy for treatment-resistant depression in adolescents. Anti-depressant effects have been demonstrated within 24 hours of receiving 1 dose of ketamine, with sustained benefit at 7 days.12 Evidence in the adolescent population is lacking at this time. Researchers hope to demonstrate that adolescents with treatment-resistant depression will also show a positive and perhaps a more sustained response to ketamine infusions. Another novel therapy known as repetitive transcranial magnetic stimulation (rTMS) may also help address the condition in youth. A noninvasive neuromodulation treatment for treatmentresistant depression, rTMS employs an electromagnetic-generated pulse to stimulate areas of the brain. This modality is FDA approved and has been shown to have improved quality of life and functional outcomes in the adult population.13 Researchers are currently studying its efficacy for adolescents, theorizing that rTMS may be as, or more, effective in treating depression in this population, given evidence that the adolescent brain demonstrates more plasticity than the adult brain.

Depression is a serious, multifaceted disorder that can have significant impacts on productivity and development. A wide array of treatment options is available, including medication and therapeutic skills. More intensive monitoring may be required when suicidal thoughts are present. Currently, several research studies are underway to explore how depressive symptoms impact brain physiology and to determine more effective treatment strategies.

Prachi Agarwala, M.D., Senior Medical Director, Child and Adolescent Psychiatry,

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University of Minnesota Health. Dr. Agarwala provides clinical care to children and adolescents admitted to inpatient mental health units and is involved in education of students, residents, and fellows at University of Minnesota Medical Center.

References 1.

Angst J, Sellaro R. Historical perspectives and natural history of bipolar disorder. Biol Psychiatry. 2000 Sept 15;48(6):445-457.

2.

Centers for Disease Control. Data from the National Health and Nutrition Examination Survey, 2009–2012 http://www.cdc.gov/nchs/ data/series/sr_13/sr13_169.pdf.

3.

Druss BG, Rosenheck RA, Sledge WH. Health and disability costs of depressive illness in a major U.S. corporation. Am J Psychiatry. 2000 Aug;157:1274-78.

4.

Kessler RC, Akiskal HS, Ames M, et al. Prevalence and effects of mood disorders on work performance in a nationally representative sample of U.S. workers. Am J Psychiatry 2006;163:1561-1568.

5.

Shepard, DS, Gurewich, D, Lwin, A K, et al.

(2015). Suicide and suicidal attempts in the United States: Costs and policy implications.

Suicide and Life-Threatening Behavior. 2016 June;46(3):352-362. doi: 10.1111/sltb.12225.

6.

CDC/NCHS, National Health and Nutrition Examination Survey, 2005–2010.

7.

Kann L, Kinchen S, Shanklin SL, et al. Youth Risk Behavior Surveillance – United States, 2013. MMWR. 2014;63(ss04): 1-168. Available from http://www.cdc.gov/mmwr/preview/ mmwrhtml/ss6304a1.htm.

8.

Centers for Disease Control and Prevention.

Injury Statistics Query and Reporting System (WISQARS). National Center for Injury Prevention and Control. 2013, 2011. Available from http://www.cdc.gov/injury/wisqars/index.html.

9.

Greenberg PE, Kessler RC, Birnbaum HG, et al. The economic burden of depression in the United States: how did it change between 1990 and 2000? J of Clin Psych. 2003 Dec;64:14651475.

10. March J., et al. Fluoxetine, cognitive-behavioral therapy and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. JAMA. 2004;292(7):807-820.

11. Brent D. et al. Switching to another SSRI or venlafaxine with or without cognitive behavioral therapy for adolescents with SSR-resistant depression: the TORDIA randomized controlled trial. JAMA. 2008;299(8):901-913.

12. Lee EE, et al. Ketamine as a novel treatment for major depressive disorder and bipolar depression: a systemic review and quantitative meta-analysis. Gen Hosp Psychiatry.

2015;37(2):178-184.

13. Solvason HB, et al. Improvement in quality of life with left prefrontal transcranial magnetic stimulation in patients with pharmacoresistant major depression: acute and six months outcomes. Brain Stimul. 2014;7(2):219-25.

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Mental Health

The Integrated Health and Wellness Clinic: A “Clinic in a Clinic” Providing Enhanced Mental Health Care

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eparating behavioral and physical health care makes it hard to get the right care, at the right time, in the right place.

It is estimated that 50% to 70% of primary care visits may involve a behavioral health “need” ranging from a mental illness or substance abuse issue to changes needed in patterns of behaviors that are impacting health and wellness. Yet when a patient is identified in the healthcare setting as needing mental health care, over 50% are unable to follow through with that referral to a therapist or a psychiatric care provider. As a result of this demand to address the individual’s global array of needs, the role of behavioral health professionals has been transforming into collaborative and consultative primary care team members.

PrairieCare opened the PrairieCare Institute in April 2015 to “Nurture Creative Innovations in Health and Wellbeing.” Our first major undertaking aligned with this goal of innovation is the design, development, implementation and ongoing operations of the Integrated Health & Wellness Clinics (IHWCs), which we currently operate within primary care clinics. In 2017, we plan to expand further into specialty clinics, trade union clinics and employer onsite clinics.

In November 2015, PrairieCare and the PrairieCare Institute partnered with our first two pioneering primary care provider partners, South Lake Pediatrics and Wayzata Children’s Clinics to open the first two IHWCs within their clinics in Maple Grove and in Spring Park respectively. This “clinic within a clinic” model has allowed an integrated team of behavioral health providers to embed within the primary care clinic as members of their medical team in order to provide comprehensive assessments, brief psychotherapy, psychiatric evaluations, brief psychiatric care, and consultation to the primary care providers. Over the course of our first 12 months, additional IHWCs were opened at another South Lake Pediatrics clinic in Minnetonka, at Fridley Children’s and Teenager’s Medical Center in Fridley, and also in two of the MultiCare Associates Clinics in Fridley and Blaine. Our therapists within these six fully-embedded IHWCs also rotate out to three additional sites and receive patient referrals from a total of 15 primary care clinic sites they are supporting in a “hub and spoke” design.

By L. Read Sulik, M.D., FAAP, DFAACAP

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Our goal has been to integrate the role of a psychotherapist and the role of a health coach into a new type of role in the health care clinic, the “Coach Therapist.” Our onsite Coach Therapists are masters or doctoral level therapists who are also trained as Health and Wellness Coaches. We also bring access to Psychiatric APRN’s, Patient Support Specialists, Clinical Care Coordinators, and board certified Adult and Child Psychiatrists. This winter, Coach Therapists will be trained in the use of a health and wellness framework of change that is based on principles of Adaptive Leadership but applied to the work of leading an individual through a process of change.

Our teams of Coach Therapists, psychiatry providers and patient support specialists, nurses and clinical care coordinators work with individuals with mental health needs and/or chronic health conditions, as well as those individuals aspiring to improve their overall health and wellness. The intention of our “clinic in a clinic” model, is to bring a standardized approach to mental health and wellness screening, scheduling, online intake information, comprehensive assessments, patient support with pre-visit and post-visit planning and coordination, brief evidenced-based psychotherapy for common mental health conditions, health and wellness therapy to improve lifestyle practices and reduce higher risk or detrimental patterns of behaviors, and access to psychiatry within the integrated team to provide psychiatric MetroDoctors

The Journal of the Twin Cities Medical Society

evaluations, precision psychopharmacological interventions and ongoing consultation with the primary care providers. Our primary “hub” clinic at the PrairieCare Institute supports all of the embedded teams of therapists and psychiatric providers across all of these sites with clinical care coordination, patient support services and nursing.

Our IHWC Team partners with the healthcare team on-site to meet patients’ mental health, behavioral change and wellness needs. We have designed ours services to help patients with their pursuit of optimal health and wellness, stress, depression, trauma and grief, child and adult ADHD, work or school pressures, coping with chronic health conditions, anxiety, alcohol and substance use problems, relationships and behavior challenges. We specifically intend to target interventions to patients with chronic health conditions including diabetes, hypertension, heart disease, asthma and COPD, pain, obesity, depression, anxiety and substance use disorders.

Our clinical interventions with our patients include evidencebased therapy practices focused throughout the treatment course preparing for lifestyle and personal change in order to develop new practices to improve sleep, diet and nutrition, physical activity and exercise, relaxation skills, awareness of negative thinking patterns, develop positive realistic thinking practices, improve communication skills to enhance connections with others and build social supports, and reactivation to improve engagement in areas of natural skills and talents and pursuits of improved understanding and growth.

We will be using the Living the Work™ Framework in our health and wellness therapy with patients. This includes

Living The Work BREATHE

SEEK

THINK

BUILD

TEND

TM

SPIRITUAL WORLD

INTERNAL WORLD

REST

THE WORK CONNECT

EXTERNAL WORLD

PHYSICAL WORLD

HYDRATE

NOURISH

BEHAVE EXPRESS

MOVE

Figure2: Living the Work™

working with patients to improve Internal World wellness practices through deep change work to improve breathing and develop routine self-soothing practices, engaging in mindfulness and yoga practices when possible, improving self-awareness, self-soothing skills, self-regulation, improve thinking patterns and develop a healthier sleep routine. Work also includes improving Physical World wellness practices through deep change work to improve hydration, adopt a healthier diet, increased and regular amount of physical activity and exercise, and regular amount of outdoor activities. We work with individuals and their External World wellness practices to undergo deep change work to improve communication and ability to express themselves, improve patterns of behaviors, and connections with others, interpersonal relationships, and communication skills. The Living the Work™ Framework also aims to improve Spiritual World wellness practices through deep change work to improve tending to internal and external roles and responsibilities, building an improved sense of self, meaning and purpose and overall wellbeing, and continuing to seek further growth and development.

The Integrated Health and Wellness Clinic Team:

We have intentionally designed an entire team that works in an integrated manner as mental health specialists in the primary care clinic where the Patient Support Specialist and the Coach Therapist are the “hub” connecting the entire IHWC Team to the Primary Care Team.

Figure1: The IHWC Diagram of Clinical Service brought “on-site” to the patient in support of the Health Care Team.

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(Continued on page 17)

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THE STRENGTH TO HEAL

and stand by those who stand up for me.

Learn the latest treatments and play an important role in the care of Soldiers and their families. As a physician on the U.S. Army Reserve health care team, you’ll continue to practice in your community and serve when needed. You’ll work with the most advanced technology and distinguish yourself while working with dedicated professionals. You’ll make a difference.

To learn more about joining the U.S. Army health care team, visit healthcare.goarmy.com/gx14 or call 952-854-8489.

©2013. Paid for by the United States Army. All rights reserved.

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Mental Health The Integrated Health and Wellness Clinic (Continued from page 15)

1. IHWC Coach Therapy Team: Our Coach Therapists are licensed mental health therapists or doctoral level psychologists who are also health coaches supporting individuals with mental health needs, chronic health conditions and those individuals aspiring to improve overall health and wellness.

Coach Therapists are the primary IHWC contact in your health care clinic. They are licensed therapists offering integrated health and wellness services that may include providing a Comprehensive Assessment of individuals’ mental health, behavioral change and wellness needs, providing emergency or urgent consultations with individuals and their health care providers, and education and collaborative treatment planning with individuals and their health care providers.

Clinical treatment services provided by the Coach Therapists include: a. Health and Wellness Coaching using Living the Work™ to improve health-related behaviors and practices b. Brief Psychotherapy c. Specialized Psychotherapy (that may be longer in duration) d. Referral to IHWC Psychiatry and other team members e. Referral to community-based specialists when needed 2. IHWC Psychiatry Team: Our board certified Psychiatrists, Child Psychiatrists and Advanced Practice Psychiatric Nurse Practitioners offer collaborative psychiatric care that may include providing consultation and collaboration with health care providers and clinical supervision, consultation, and collaboration with coach therapists and the patient support team; psychiatric evaluations, precision psychopharmacology using pharmacogenetics, brief psychiatric care as well as in some instances brief psychotherapy with the intention of having the patient return to the referring primary care provider as soon as possible.

3. IHWC Nursing Team: Our nurses (Registered Nurses) work with patients on the phone. They support the psychiatric provider to help with psychiatric needs, including serving as a contact for psychiatry services, addressing refill requests, answering medication questions and concerns, and providing supportive communication about mental health needs.

4. IHWC Patient Relations Team is made up of our Clinical Care Coordinators and support staff who are located in the “hub” at the PrairieCare Institute as well as Patient Support Specialists who are mostly located on site in the embedded IHWC with the Coach Therapists and the Psychiatry providers. Our Clinical Care Coordinators coordinate IHWC services with the primary care clinic that may include scheduling appointments, connecting with community providers, addressing billing questions, checking insurance coverage, answering questions about IHWC services. Our Patient Support Specialists help individuals at the clinic or on the phone MetroDoctors

The Journal of the Twin Cities Medical Society

providing services that may include scheduling support, helping individuals complete the initial information packet and required forms, collecting records, pre- and post-visit support of the patient We believe our approach is patient-centered and provides seamless communication to the patient and their healthcare team using advanced technology such as our newly developed web-based screening, intake, assessment and monitoring platform and our newly developed telehealth platform. We are also developing standardized assessment of acuity and complexity that drive patient-specific treatment plans based on evidence-based research. Seamless communication is a key goal we are constantly trying to achieve and seems to be one of the critical components of successful integration. We intend to demonstrate that through our technology and our recent build of screening tools, intake forms, assessments and collaborative treatment planning that are designed to flow together we are able to achieve not only this “seamless” communication but significantly improved patient engagement and clinical outcomes with reduced total cost of care.

We are able to forecast that we will be reducing pharmaceutical costs, emergency room visits and hospitalization costs for mental health conditions, yet we also forecast an impact on savings on individuals with chronic health conditions.

As we partner with employer onsite clinics, we intend to demonstrate improvements in employee wellness, performance and productivity. We intend to have a tremendously positive impact on quality outcomes of care, total cost of care, improved employee performance and productivity (with reductions in absenteeism and presenteeism rates) as we integrate into employee onsite or near-site clinics in addition to the primary care and specialty clinics. So much of our forecasting of this impact comes from adapting the workflow and overall operations of these clinics to best fit each of our partner clinic sites.

L. Read Sulik, M.D. is a graduate of the University of Minnesota Medical School and completed his Triple Board residency in Pediatrics, Adult Psychiatry and Child and Adolescent Psychiatry at the University of Kentucky. Dr. Sulik is Chief Integration Officer at PrairieCare and the Executive Director of the PrairieCare Institute.

Previously Dr. Sulik served as the Assistant Commissioner of the Minnesota Department of Human Services over the Chemical and Mental Health Services Administration, and Medical Director of Child and Adolescent Psychiatry at St. Cloud Hospital/CentraCare Health System. He may be reached at PrairieCare Institute, 1934 Hennepin Avenue South, Suite 300, Minneapolis, MN 55403; rsulik@prairie-care.com; (952) 737-4566.

January/February 2017

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Sponsored Content

The Evolving Care of Patients with Eating Disorders Contributed by Joshua Zimmerman, M.D. Eating disorders are the most lethal of all psychiatric conditions. Studies suggest that anorexia nervosa carries a mortality risk as many as 20 times that of an age-matched population, with risk increasing the longer a patient struggles with the illness. Rates of anorexia are steadily rising in Western countries and around the world. Comorbidities such as substance use disorders, post-traumatic stress disorder and depression are becoming more the rule than the exception.

Melrose Center is the region’s leading not-for-profit provider of eating disorder care. For more than 30 years, Melrose has helped treat and heal patients using a multidisciplinary approach that includes medical, nutritional, psychological and behavioral care. All three locations, in St. Louis Park, Maple Grove and St. Paul, provide initial assessments and outpatient services. While 90% of patients require only outpatient care, the St. Louis Park site also offers higher levels of care, including a 39-bed intensive residential unit to care for patients with acute needs. Melrose Center also offers specialty care for co-occurring eating disorders and substance abuse or type 1 diabetes.

Partnership and Innovation As eating disorders become more complex and common, evidence-based research to improve clinical outcomes, patient experience and total cost of care is needed. Melrose Center worked with HealthPartners Institute, HealthPartners’ medical research and education center, to identify three key areas for partnership, research, and process 18

January/February 2017

information could be applied to patients with anorexia nervosa.

Working with HealthPartners Institute, Melrose Center developed a refeeding protocol designed to double the rate of weight restoration during inpatient treatment to 4 pounds per week. This protocol included regular monitoring of glucose, liver function and electrolytes to watch carefully for refeeding syndrome. The protocol was well tolerated, and only two patients experienced mild hypoglycemia.

improvement: refeeding, outcomes measures and opiate detoxification with Suboxone® (buprenorphine and naloxone).

Refeeding Protocol The mainstay of anorexia nervosa treatment is refeeding paired with evidencebased psychotherapy. Traditionally, severely malnourished patients who restored more than 2 pounds of weight per week were feared to be at high risk for the refeeding syndrome, a complex medical occurrence likely triggered by adenosine triphosphate (ATP)/phosphorous depletion and a massive insulin spike. Refeeding can result in electrolyte abnormalities, hypoglycemia, hepatitis and death. Much of the research on refeeding syndrome, however, was conducted after World War II on severely ill victims of concentration camps. It was never clear if this

Outcome Measures Relatively little research has been done on the effectiveness of different treatments for anorexia nervosa and other eating disorders. Cognitive behavioral therapy and family-based therapy are evidence-based approaches, but the evidence behind these approaches generally excludes patients with comorbidities or who are very ill.

Working closely with HealthPartners Institute, Melrose Center developed a series of outcomes measures for all patients, with no exclusions. These measures included a global assessment of eating disorder severity and measurements of depression and anxiety severity. We used tablet-based computers to make entering the information as easy as possible for patients and included the results in real time in the vital signs section of the patient’s medical record. Patients had highly statistically and clinically significant improvements in all three areas, as measured from beginning of treatment to six-month follow-up. We have simplified the measures slightly to reduce the time burden on patients. We

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In addition to research and clinical treatment, Melrose Center provides integrative therapies to treat mind, body and spirit. One example is this labyrinth which offers walking meditation.

are now in the process of breaking down our measures by comorbidity so we can look for opportunities to further refine clinical programming.

Research on outcomes for eating disorders has produced varying results.

However, roughly 50% to 70% of patients

patients generally respond to Melrose’s evidence-based treatment interventions.

Suboxone Treatment Minnesota is in the middle of an opiate epidemic. Up to 30% of patients with bulimia have a severe substance use disorder.

Using heroin to numb flashbacks or fight constant urges to binge and purge can feel better than dealing with these symptoms on a daily basis. make a full recovery; up to 30% have relapses; and, in about 20%, the eating disorder becomes chronic. Outcomes depend on factors such as diagnosis (anorexia nervosa is most difficult to treat), time from onset of the eating disorder to intervention (earlier treatment typically predicts a better outcome) and social support.

Data for Melrose Center-specific patients are not available at this time.

However, the center is collecting patient outcome data to evaluate how it compares with other treatment centers and how MetroDoctors

Melrose Center found that, although we had excellent partnerships with local substance abuse treatment centers, patients with opiate addiction were not receiving optimal care. Opiates are a powerful and destructive method of coping. Using heroin to numb flashbacks or fight constant urges to binge and purge can feel better than dealing with these symptoms on a daily basis. However, when patients sought out substance abuse treatment, their eating disorders raged out of control, and treatment centers could not safely manage

The Journal of the Twin Cities Medical Society

their conditions. When Melrose Center attempted to treat patients addicted to opiates for their eating disorder, their withdrawal was so severe that patients often left treatment or could not participate. As a result, several Melrose Center physicians obtained Suboxone certification. Protocols were designed for in-house opiate detoxification, aiming to bring opiate withdrawal symptoms under control within 36 hours so that patients could quickly transition to eating disorder programming.

Conclusion Eating disorders are increasingly common, complicated and lethal. An approach that combines clinical work, research and Triple Aim goals is required to be on the leading edge of eating disorder treatment.

Joshua Zimmerman, M.D., attended Medical School at Case Western Reserve University and completed his residency at the Harvard Longwood Psychiatry Residency Training Program. He has worked for Park Nicollet and HealthPartners for 10 years. He is the Senior Medical Director for Behavioral Health, and an adult psychiatrist, with an area of focus in eating disorders.

January/February 2017

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Mental Health

Greater Mental Health Outcomes Require Coordinated Effort Against Social Stigmas

M

ental health and substance use disorders have been receiving increased attention over the last few years and as we recognize the challenges, we are presented with an unprecedented opportunity. The Mental Health Parity Act (MHPA) is a tremendous callto-action for providers and payers to treat behavioral health in the same way we treat physical medicine. Recently, there has been an increased awareness of addiction and we must improve the ways we conceptualize and treat individuals. There is an increased understanding of the need to focus on emotional well-being as we find this has real-world impacts on productivity and other economics as well as quality of life.

I have spent the majority of my career as a physician providing direct care to patients and their families. I moved into the health plan arena because I wanted to be able to affect systemic changes on a larger scale, specifically the “artistic” nature of behavioral health. Quality and evidencebased care still elude us at times because of varying diagnoses and treatment options.

How do we measure quality? I don’t think we’re all in agreement. We look to our professional organizations, but measurement is still a significant challenge. In physical medicine, we have moved toward risk-sharing arrangements and paying for improved outcomes. This benefits the payers because our members are healthier and the administrative costs can be less.

It also benefits the providers because they want to do meaningful work and these

By Misty Tu, M.D.

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January/February 2017

arrangements could significantly lessen the administrative burden which would allow providers to focus on treating patients.

Finally, there are benefits to individuals as more money can be funneled into providing treatment, which pushes the providers to work towards being more outcome driven and focus on the true coordination of care. Case rate payments and risk sharing arrangements can only be accomplished if the payers and providers can assume positive intent and work together. The fee-for-service model that is typically used today pays the same for “good care” as it does for “bad care,” and it is an episodic approach to a chronic illness. Even though it isn’t optimal, it is difficult to change unless there is an incentive. Ultimately, we are moving towards a place where it is not only undesirable, but also unsustainable.

The MHPA has been a significant piece of legislation. I view it as a large

step to destigmatize mental health and substance use disorders by adding validation to the understanding that they are diseases and have similarities to the diseases in physical medicine. However, as we make adjustments for parity, we do have to recognize the differences. For example, does physical rehabilitation equate to mental health or substance use disorder rehabilitation? Physical rehabilitation is often done as episodic after an injury or repair where mental health and substance use disorder rehabilitation is directed to treat a chronic illness. It seems fairly obvious that the lifelong learnings of adaptation, recovery, and living do not appear to be the same as rehabilitation after a hip replacement.

With these differences in mind, we need to take the best that this legislation has to offer, but temper it with judicious application and thoughtfulness.

Substance abuse and addiction has been an issue for decades if not centuries.

With the advent of synthetic materials, this has become increasingly deadly and costly. Everything from synthetic marijuana to opioid prescription medications has changed the intensity and progression of this illness along with crossing nearly all demographic lines. As I stated earlier, we have to turn away from the idea of episodic care and look at the continuum of the disease. We have to be willing and able to share potentially life-saving information with other providers and family members as well as with patients. We must decrease the stigma of substance use disorder by treating it like physical illness, and one way to achieve that is to lift the veil of secrecy

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that we often self-impose. I am not naïve enough to believe there is no risk in this approach. I know there are still consequences to being identified as an “addict,” but we must demand that providers and payers treat these individuals with respect and compassion as we do individuals with other illnesses. We cannot build enough inpatient or residential beds to tackle this problem. They obviously have a crucial place in the treatment paradigm, but we need more meaningful ways to engage individuals in their ongoing sobriety and recovery. For several years now the funding and amount of money paid out for treatment has increased, but the overall outcomes worsen year-after-year.

A significant barrier to accessing care is the alarming shortages in providers for mental health and substance use disorder throughout the country. There are multiple ways to address this issue such as increasing the number of providers by loan forgiveness programs, funding for increased residency positions, and other incentive programs. Technology is another way to expand the availability of care by utilizing telemedicine and online applications such as cognitive behavioral therapy and mindfulness training. Another avenue to increase provider access is for increased collaboration by mental health professionals and primary care physicians. For example, when the primary care physician identifies an individual as being in distress, the patient is referred and seen by a mental health professional. As that individual begins to stabilize, the mental health professional will work to transition the care back to the primary care physician. Following the transition, the mental health professional can continue to provide support for treatment planning in a consultative role.

This reopens the mental health professional’s schedule for additional patients.

We should also consider that an enhanced reimbursement arrangement may need to be considered for this additional level of accountability.

Health plans have multiple purposes to serve and they have to bring value to MetroDoctors

its members. One of the values is to help guide members through the often complex world of health care and to help integrate information. While general care providers are becoming more integrated through electronic medical records and information sharing, mental health and substance use disorder providers have not all embraced this movement. There are also logistical barriers for solo practitioners, but it is becoming more of a necessity and a qualityof-care issue to not collaborate with the other providers involved in the care of the individual.

There are many challenges we still face — no one person, legislature, provider or health plan has the answer. Now is a time for active examination and changes

The Journal of the Twin Cities Medical Society

in our systems. We must work together to decide on the future state of mental health and substance use disorder treatment. We must always keep in mind the person at the other end of the diagnosis and how they are impacted by the disease, along with their family, their employers, and their communities.

As Senior Medical Director for Psychiatry and Behavioral Health, Dr. Misty Tu serves as Blue Cross and Blue Shield of Minnesota’s clinical leader for the company’s psychiatry and behavioral health management functions. Dr. Tu holds a bachelor’s degree from the University of Texas at Dallas and a doctor of medicine degree from Texas Tech Health Sciences Center. She completed her psychiatric residency at the University of Southwestern Medical Center. Dr. Tu holds medical licenses in Texas, Arizona, California, Louisiana and Minnesota. She is certified as a diplomat with the American Board of Psychiatry and Neurology. She can be reached at: Misty.Tu@ bluecrossmn.com.

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21

Mental Health

Chances Are

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hances are, you have seen a patient with a mental illness or who has a loved one with a mental illness.

Chances are you also were not sure what to do or what to say. Many physicians — except psychiatrists — feel uncomfortable talking about or treating mental illnesses.

Yet, it is common, impacting one in five people with a range of intensity from mild, to debilitating to disabling.

Many people with depression or anxiety seek help in primary care. Women with Postpartum Depression (PPD) are seen in OB/GYN clinics. Pediatricians also see PPD along with childhood mental illnesses. Depression often accompanies many other illnesses such as diabetes, heart disease, multiple sclerosis, or cancer. ED physicians also see people experiencing a mental health crisis such as suicidality, panic attack, mania or psychosis.

You may very well be the first physician that an individual or family member talks to about a mental illness. Providing empathy and understanding and referring them to resources at the National Alliance on Mental Illness (NAMI) along with providing or referring them to appropriate treatment will lead to better outcomes.

Recovery is possible and probable when people receive appropriate help and when they know they are not alone.

Mental illnesses don’t fit neatly into a box anymore. Treating people holistically and through integrated care is increasingly important. Due to the shortage of mental health professionals, people need to be treated through whichever door they come in. They are everyone’s patients.

NAMI Minnesota does not believe we

By Sue Abderholden, MPH

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January/February 2017

have a broken mental health system.

The reality is that discrimination under public and private insurance has resulted in a greater reliance on block grants. Block grants are lump sums sent to counties or states to use to pay for treatment and services with few strings attached; they are not reimbursements for services rendered.

You cannot build a part of the health care system with block grants.

The good news is that we have started to build our mental health system and we have more services than ever before. The additional good news is that the cloak of silence around mental illnesses is beginning to be pulled back resulting in more people seeking care than ever before. The bad news is that this is placing even more strain on our fragile “just being built” mental health system.

So what is a physician to do? NAMI Minnesota is here to help you and your patients. NAMI is dedicated to improving the lives of children and adults with mental illnesses and their families through education, support and advocacy. Nearly 100% of our staff, board and volunteers either live with, or have a family member with a mental illness so we provide peerto-peer support.

Knowing the difficulty in obtaining information NAMI Minnesota has published 12 different booklets on a variety of topics such as the adult or children’s mental health system, psychiatric hospitalization, juvenile or criminal justice system, planning for a mental health crisis, data practices, and transition age services. A brand new booklet has been placed on the National Institute of Mental Health’s

website on understanding psychosis. All can be downloaded from our website or copies can be sent out free of charge (namimn.org).

Patient and family education is important to recovery and to preventing readmissions. NAMI Minnesota offers nine different free classes that provide information on adult and children’s mental health issues and range from a two-hour class to a one-day class, to a 12-week Family-toFamily class, which is a “life-saver” for many families. They learn about mental illnesses and how to help their loved one.

Children’s Challenging Behaviors is a oneday class for parents of children who are exhibiting signs of mental illness.

Understanding Early Episode Psychosis helps family members and loved ones of a person who has experienced psychosis understand symptoms, causes and treatments along with how to help a young person get back to work, school and achieve recovery.

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Evaluations of NAMI’s education programs consistently demonstrate that over 90% of the attendees found the classes increased their knowledge and feeling of connectedness to others and that they feel better able to advocate for and help their loved ones. Knowing you do not have time to provide all the education and support that is needed, referring your patients to a NAMI class is an important first step.

More than 70 NAMI peer support groups are held across the state to provide access to free support for adults living with a mental illness, young adults with mental illnesses, people who identify as LGBTQ, family members, parents of children, spouses/partners, adult sons and daughters, and parents who have a child with a fetal alcohol spectrum disorder (FASD). People with the lived experience and who have gone through special training lead these groups. This can be a very lonely journey and knowing others who have “been there” is critically important and helpful.

NAMI also works to increase the mental health literacy of the community so that people recognize signs and symptoms earlier and know what to do. We provide education to students and the general public through a variety of programs, including Mental Health First Aid and Ending the Silence. Outreach to professionals is done through two online classes and in-person classes for teachers, police and health care professionals.

Suicide prevention is also an important part of our work. Knowing how to talk about and especially how to restrict access to lethal means is important for any clinic. Families should be told to remove guns from the home when a family member has a mental illness or is suicidal and should lock up (with a key) prescription and over-the-counter medication.

The high rate of smoking among people with mental illnesses has also led NAMI to promote effective smoking cessation strategies. We are happy to provide materials and conduct in-service trainings for staff.

There is a special class for teens and young adults with mental illness called Progressions. It is a six-week class that

MetroDoctors

teaches young people how to maintain good mental health; how to recognize signs of stress, anxiety, depression and bipolar disorder; how to help friends, siblings and parents understand what they are going through as well as different types of treatment options.

A non-emergency helpline is available to answer the questions of your patients, families or staff and to direct them to community resources. Another important resource for any physician is our mental health crisis system in Minnesota. Calling a mental health crisis team rather than 911 can result in a child or adult being assessed and provided help rather than entering the criminal justice system. Post your county’s number in your office so that people are aware of it.

Lastly, assess your office environment.

People who are not doing well with their health care issues often have a co-occurring but untreated mental illness. Are there materials in the waiting room or exam rooms with information about mental illnesses such as fact sheets on depression,

The Journal of the Twin Cities Medical Society

crisis lines, and NAMI materials? Having the information there lets patients know you are okay talking about it. Do you conduct depression screenings for youth and adults? Early identification and treatment are critical to good outcomes. Conducting screenings and discussing the findings makes it easier to open the door to talking about mental illnesses as well.

We hope that you will use the many resources offered to the community to improve the lives of children and adults with mental illnesses and their families.

We are here to help!

Sue Abderholden, MPH, has been the Executive Director of NAMI Minnesota for over 15 years. She has over 30 years of experience in improving public policies for people with disabilities and mental illnesses and in nonprofit management. She has received numerous awards for her advocacy. She has family members who live with a mental illness. She can be reached at: (651) 645-2948; namihelps@namimn.org; www.namihelps.org.

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January/February 2017

23

Mental Health

In Mental Health, Talk of Hope and Recovery is Key to Improving Lives Kate* first began struggling with symptoms of bipolar disorder when she was 19 years old. A college freshman away from home for the first time, she struggled to make sense of what was happening, and turned to alcohol and drugs as a way of coping with symptoms she didn’t understand… symptoms of a mental illness that hadn’t yet been diagnosed. She stopped attending her classes and left college later that semester, ashamed but still unable to understand what had happened.

After returning home, Kate’s parents tried to help. Their first stop was the family’s longtime primary care doctor, who prescribed an antidepressant and suggested she see a therapist. She did, but her symptoms continued to get worse instead of better.

Kate was unable to maintain employment or continue her education, and she felt hopeless.

“It was hard to see what there was to live for,” says Kate. “It was like I was living someone else’s life that I had no control over, and no future to look forward to.”

Over time, Kate received a diagnosis of bipolar disorder and worked with a psychiatrist to find the right medication to help her manage her symptoms. She also started working with a new therapist who used a word Kate hadn’t heard before: recovery.

“No one had told me that I could ‘recover’ from my mental illness before that day,” said Kate. “It gave me hope for the future.”

Kate eventually finished college and now has a successful career. She has also

By Shannah C. Mulvihill

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January/February 2017

become an advocate for mental health recovery and access to treatment and services people need to get better.

“It took me a long time to get better, and it’s my hope that my story helps others get help sooner. I also want health care professionals to know how important it is to provide hope for recovery to those facing mental illness…for me, that was life changing.”

The concept of “recovery” is still a fairly new one in the world of mental health treatment and services. Until the 1950s, many people facing mental illness lived in state institutions. Limited options for treatment existed, and there was little hope for those facing mental illness and their families that things could ever get better.

Today, we look at mental health very differently. The belief that recovery from mental illness is possible is prevalent.

There are many more options for treatment and services for those living with mental illnesses. Although we still have a long way to go to ensure that people have access to the help they need to recover, we have come a long way.

Still, mental health recovery does not always mean “complete” recovery from a mental illness, at least not in the same way that recovery is often thought of when it comes to physical health concerns. For many people living with mental illness, recovery is about managing a chronic condition (and its symptoms) and building the resiliency, tools and support system they need to live a meaningful life.

The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”

At Mental Health Minnesota, we refer to a mental health “recovery journey,” because we know that ups and downs often occur, and no two paths to recovery are the same. We believe that engagement is where recovery begins, because it ensures that those living with mental illness know the options for care and treatment that are available and make choices that reflect their goals and individual journey to mental health recovery.

The first step, however, is often having the resources and help needed to move forward.

Alex* called Mental Health Minnesota

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from a hospital after learning he would be discharged the next day. Prior to going to the emergency room and his ensuing hospitalization, Alex saw a primary care physician a few times per year but did not have a support system set up to address his mental health concerns, although he was taking several medications prescribed by his doctor to help address his symptoms.

Alex wanted to seek help and felt that, following his mental health crisis and hospitalization, he needed an intensive treatment program to learn to manage his mental illness. However, he was also concerned that doing so would also mean loss of his full-time job, as well as his health insurance.

serious mental illness, it’s not just a fact, it borders on a public health crisis.

People in Minnesota who are living with a serious mental illness die, on average, 24 years earlier than their peers.

24 years earlier! And while suicide is more common among those living with serious mental illness than the general population, the leading causes of death are heart disease, unintentional injury, COPD and cancer.

According to SAMHSA, this gap in life span has actually increased, not decreased, over the last 30 years. So, even as treatment and services for mental health have continued to improve, there is a

Mental Health Minnesota’s peer advocate helped Alex identify a partial hospitalization program and other resources that would help him move toward mental health recovery, as well as make an appointment to see a psychiatrist. She also helped him contact human resources at his company to arrange for the leave he needed for treatment that would ensure his employment and insurance were secure.

“I needed to keep my job, but I also knew that I needed help to get better,” said Alex. “Landing in the hospital meant I couldn’t continue to just ‘get by’…I needed more.”

For many people, the gateway to mental health care has become primary care, or in the event of a crisis, a hospital emergency room. So how can we all do more to ensure people get the help they need, when they need it?

First, we should all recognize and appreciate the fact that mental health and physical health are, without a doubt, woven together. And for those facing

need to further integrate the way we approach health care — physical health and mental health cannot be stand alone entities if we are to address this troubling trend.

Mental Health Minnesota recently initiated a survey to learn more about the barriers people living with a serious mental illness face in managing their health. We are hoping that our work will help healthcare providers think differently about their work and improve outcomes for their patients. A number of people completing the survey said that they felt their primary care doctor did not understand or address the individual barriers they were facing in pursuit of physical health, especially the impact of psychotropic medications, which can cause weight gain, lethargy and a number of other side effects.

So what can healthcare providers do?

Ask your patients about their goals. Understand their challenges. Know when and where to refer a patient for more

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help. Look at the whole person. And know that one in five people will face a mental health concern at some point during their lifetime, and at one point or another, will walk through your office door. * Names have been changed to protect privacy.

Founded in 1939, Mental Health Minnesota was the state’s first mental health advocacy and education organization. Services include the Minnesota Warmline, an anonymous phone line for those working on their mental health recovery, as well as Peer Advocacy, which helps people overcome hurdles and gain access to the treatment and services needed in their mental health recovery. Both services utilize a peerto-peer approach, providing support to people through a lived experience perspective. Mental Health Minnesota’s free services are available to people across Minnesota, and healthcare providers are encouraged to refer patients who need help. For more information about services, resources and education, visit www.mentalhealthmn.org.

Shannah Mulvihill is the Executive Director of Mental Health Minnesota, which works to enhance mental health, promote individual empowerment, and increase access to treatment and services for persons living with mental illnesses. Shannah has worked in the non-profit sector for more than 16 years in the areas of communications, development, public policy and organizational leadership. She has also served on boards at The Cancer Benefit Fund of Minnesota and the American Red Cross, and is a former board chair of Open Your Heart to the Hungry and Homeless. Shannah holds a Masters Degree in counseling psychology, and has served as a volunteer counselor for the Walk-In Counseling Clinic and Crisis Connection.

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Mental Health

Kicking the Habit: Promoting Tobacco Cessation for People with Mental Illness

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s you have read throughout this issue, individuals experiencing mental health issues face a complex array of challenges unique to their conditions. Many people with mental illness also share a common challenge: tobacco use and nicotine addiction. Though the overall smoking rate for the general population has been steadily declining in the United States, the smoking rate among people with these diagnoses remains high.1 Over 1 in 3 adults (36%) with a behavioral health diagnosis use cigarettes compared to 1 in 5 adults (21%) with no mental illness.2 These disparities are particularly pronounced among people with serious psychiatric diagnoses, where people with schizophrenia are three to seven times more likely to smoke than the general population and people with bipolar disorder are three to four times more likely to smoke than those without the disorder.3-5 In addition to high rates of smoking, people with mental illness also smoke more cigarettes per month than those without.2 These disparities, which are likely related to both biochemistry and social factors, contribute to high morbidity and premature mortality rates among this population.

As with the general population, smoking is the leading cause of preventable death among individuals with mental illness. People with serious psychological disorders have a reduced life expectancy of 10 to 15 years compared

By Peter Dehnel, M.D., and Annie Krapek

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January/February 2017

Annie Krapek

Peter Dehnel, M.D.

to those without, in part due to heavy daily smoking and limited access to high quality health care.6 Alarmingly, recent research shows that 50% of deaths among individuals with schizophrenia, depression and bipolar disorder can be linked to tobacco or tobacco smoke exposure.7 In addition to impacting morbidity and mortality, tobacco use can act as a barrier to community integration for people with behavioral health diagnoses.

This can be seen in the decrease of the likelihood of finding employment and housing among smokers, which in turn impacts access to health care.

In some cases, the nicotine inhaled from smoking may work to mask symptoms and/or medication side effects in people with mental illness.8 However, because smoking delivers nicotine along with hundreds of other toxins and

carcinogens and has numerous other adverse health impacts, it is clearly not a desirable means of treating mental illness. Providers should consider using alternate nicotine delivery systems or treatments with the goal of tobacco cessation.

As with many aspects of behavioral health disorders, there are numerous misconceptions about tobacco use among people with these diagnoses. One misconception is the belief that quitting tobacco may worsen mental illness by triggering nicotine withdrawal. A growing body of evidence shows that smoking cessation is actually associated with improved long-term mental health outcomes and that smoking cessation is linked to decreased anxiety and depression, and improved mood and perceived quality of life.9

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The Journal of the Twin Cities Medical Society

Another common misconception is the perception that people with psychiatric disorders are not interested in smoking cessation. In actuality, people with serious mental illness report being as motivated to stop smoking as people without serious mental illness.10 Despite this motivation, individuals with these diagnoses have lower lifetime quit rates than those without. This trend is particularly pronounced among people with serious mental illness.11 Many factors may contribute to low quit rates, including increased nicotine dependence, failure to promote smoking cessation to people with behavioral health disorders and barriers to accessing smoking cessation services.

The good news is that physicians can help increase quit rates among their patients with these diagnoses and disorders.

Physicians can use the 5 As (ask, advise, assess, assist and arrange) to address tobacco use with their patients who have mental illness, just as they would with their patients without those diagnoses.

Nicotine replacement therapy, including skin patches, chewing gum and lozenges, are effective cessation tools for individuals facing mental health issues.

Just as with other patients with nicotine dependency, Zyban (bupropion HCl)) and Chantix (varenicline tartrate) can also be considered. It is important to point out that there are additional cautions related to their use among this population. Zyban has been associated with the adverse side effects of: • Activation of mania/hypomania • Psychosis and other serious neuropsychiatric events and reactions • Increase in suicidal thought • Its use is contraindicated in patients with a history of bulimia and/or anorexia Chantix, likewise, has the following cautions and side effects listed: • Serious neuropsychiatric events and/ or reactions • Agitation, hostility, depressed mood or changes in behavior or thinking MetroDoctors

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Increase in suicidal ideation while on Chantix or shortly after its discontinuation There are actually a number of clinical trials in progress working on the best practice recommendations for use of Chantix and/or Zyban in this population. Some of these clinical trials are listed at the government’s official clinical trial website: www.clinicaltrials.gov.

It is also important to note that nicotine withdrawal itself can have significant behavioral health manifestations even in patients without underlying mental health disorders. These withdrawal symptoms may be exacerbated in this particular population. Warning patients, significant others, caregivers and other potentially affected individuals is critical for the best achievable outcome.

Cessation counseling is also an effective cessation tool, and a combination of medication and counseling has been shown to be more effective than either used alone.8 The cost of smoking cessation services is covered by commercial health plans, Medical Assistance and MinnesotaCare, and uninsured individuals can access cessation services through QUITPLAN® Services. Providers can use QUITPLAN® Services and the Call it Quits referral program to easily connect their patients to cessation services.

By connecting nicotine dependent patients who have other mental health disorders with the appropriate cessation services, physicians can work to help improve their patients’ mental and physical health. Given their higher rates of tobacco use, it is critical to make a concerted effort to bring down their nicotine consumption. Some of the additional cautions in treating this group of patients are listed above. But, at the end of the day, this is a group of people that desperately needs our assistance to improve their health going forward.

Coordinator, Physician Advocacy Network; akrapek@metrodoctors.com.

References 1.

Cook, B. L., Wayne, G. F., Kafali, E. N., Liu, Z., Shu, C., & Flores, M. (2014). Trends in Smoking Among Adults With Mental Illness and Association Between Mental Health Treatment and Smoking Cessation. JAMA, 311(2), 172-182.

2.

Center for Disease Control and Prevention.

(February 5, 2013.) Vital Signs: Current Cigarette Smoking Among Adults Aged ≥18 Years with Mental Illness – United States, 2009–2011.

MMWR. Morbidity and Mortality Weekly Reports. Retrieved from http://www.cdc.gov/ media/dpk/2013/docs/dpk-vs-adult-smokingmental-illness-hyde_MMWR.pdf.

3.

Leon, J. D., & Diaz, F. J. (2011). Genetics of schizophrenia and smoking: An approach to studying their comorbidity based on epidemiological findings. Human Genetics, 131(6), 877-901.

4.

Leon, J. D., & Diaz, F. J. (2005). A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors. Schizophrenia Research, 76(2-3), 135-157.

5.

Jackson, J. G., Diaz, F. J., Lopez, L., & Leon, J. D. (2015). A combined analysis of worldwide studies demonstrates an association between bipolar disorder and tobacco smoking behaviors in adults. Bipolar Disorders, 17(6), 575-597.

6.

Sharma, R., Gartner, C. E., & Hall, W. D. (2016).

The challenge of reducing smoking in people with serious mental illness. The Lancet Respiratory Medicine, 4(10), 835-844.

7.

Callaghan, R. C., Veldhuizen, S., Jeysingh, T., Orlan, C., Graham, C., Kakouris, G., Remington, G., Gatley, J. (2014). Patterns of tobaccorelated mortality among individuals diagnosed with schizophrenia, bipolar disorder, or depression. Journal of Psychiatric Research, 48(1), 102-110.

8.

Annamalai, A., Singh, N., & O’Malley, S. (2015).

Smoking Use and Cessation Among People with Serious Mental Illness. Yale Journal of Biology and Medicine, 88, 271-277.

9.

Taylor, G., McNeill, A., Girling, A., Farley, A., Lindson-Hawley, N., & Aveyard, P. (2014).

Change in mental health after smoking cessation: Systematic review and meta-analysis.

Bmj, 348(Feb13 1).

10. 1Siru, R., Hulse, G. K., & Tait, R. J. (2009). Assessing motivation to quit smoking in people with mental illness: A review. Addiction, 104(5), 719-733.

11. McClave, A. K., McKnight-Eily, L. R., Davis, S. P., & Dube, S. R. (2010). Smoking Characteristics of Adults With Selected Lifetime Mental Illnesses: Results From the 2007 National Health Interview Survey. American Journal of Public Health, 100(12), 2464-2472.

Peter Dehnel, M.D., is the Medical Director, Physician Advocacy Network, and Annie Krapek serves as Assistant Project

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Mental Health

Environmental Health — Mental Health Effects of Our Changing Climate

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elcome to the first in a series of columns from the TCMS Environmental Health Task Force. We look forward to bringing you information on environmental health concerns important to physicians and their patients.

There is evidence that changes in Minnesota’s climate (due to Global Warming) may be affecting the incidence and prevalence of certain health conditions.

The state has seen an increased frequency of consequential precipitation and floods.

Our warm seasons are growing longer and

wetter; summers are hotter and more humid.(1) The longer pollen seasons have contributed to increasing allergic disorders and asthma; air pollutants (e.g. microparticulates and ozone) are a factor in cardiopulmonary morbidity and mortality; and there is an increasing incidence of vector-borne diseases.(1) Mental health issues, highlighted in this issue of MetroDoctors, are also associated with environmental changes. The increased frequency and severity of extreme weather events have caused losses of homes, income, businesses, property

and crops, with the attendant processes of clean-up and recovery, as well as physical trauma and, at times, loss of life. These stresses increase the risks and severity of anxiety disorders, depression, and posttraumatic stress disorder (PTSD). This has been well-documented after extreme weather events around the country. For example, the incidence of PTSD and major depression increased by 23% in areas affected by Hurricane Katrina;(2) suicidal ideation and severe mental illness nearly tripled within a year following the storm.(3) Those at greatest risk include persons with pre-existing mental illness, those with low incomes and limited financial resources, those who have previously experienced loss and trauma from disaster events, isolated individuals with limited support networks, and First Responders.(4) MDH has created an excellent resource, Mental Health, Climate Change and Public Health Training Module,(5) for further information.

Questions or comments may be submitted to Sue Schettle (sschettle@metrodoctors.com).

References: 1.

Minnesota Climate & Health Profile Report.

Minnesota Department of Health. St. Paul, MN. February 2015 (health.mn.gov/climatechange/).

2.

Galea, D., M. Tracy, F. Norris and S.F. Coffey. ”Financial and Social Circumstances and the Incidence and Course of PTSD in Mississippi during the First Two Years after Hurricane Katrina.” Journal of Traumatic Stress 21:357-68 (2008).

3.

Kessler, R.C., S. Galea, M.J. Gruber, N.A. Sampson, R.J. Ursino and S. Wessely. “Trends in Mental Illness and Suicidality after Hurricane Katrina.” Molecular Psychiatry 13:374-84 (2008).

4. http://www.health.state.mn.us/divs/climatechange/mental.html.

5. http://www.health.state.mn.us/divs/climatechange/mental.html#links.

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Patrick J. Flynn, M.D. Receives Charles Bolles Bolles-Rogers Award

T

he Twin Cities Medical Society Foundation has the unique honor of selecting and presenting the Charles Bolles Bolles-Rogers Award. The award (a bowl) is named after Mr. Charles Bolles Bolles-Rogers, an “aristocratic” and philanthropic gentleman who lived in the Minneapolis area for 37 years and was especially interested in the health and hospital needs of the city. He served on the (former) St. Barnabas Hospital Board of Trustees and was president of that board for many years. Prior to his death he made provision for the Charles Bolles Bolles-Rogers Award to be given annually to an outstanding physician.

Patrick J. Flynn, M.D. is the 2016 recipient of the Charles Bolles BollesRogers Award. Dr. Flynn, a highly accomplished and dedicated oncologist/ hematologist associated with Minnesota Oncology is widely recognized for his clinical research — particularly serving for 30 years as the principal investigator for the National Cancer Institute Grant Funded Metro Minnesota Clinical Community Oncology Project (CCOP). It was his vision to bring together, often fiercely competitive, cancer care providers and institutions throughout the Twin Cities for a common cause — where thousands of patients were enrolled in cancer investigation trials.

Dr. Flynn has been described as an excellent and compassionate physician, an outstanding teacher and a leader in cutting-edge research. His colleagues agree. In March 2013, Dr. Flynn received the Association of Community MetroDoctors

Drs. Frederick Bolles Rogers (L) and TCMSF Board Representative Andrew Thomas (center), present the 2016 Charles Bolles Bolles-Rogers Award to Patrick J. Flynn, M.D.

Cancer Centers’ David King Community Clinical Scientist Award, which recognizes the top clinical oncologists throughout the country.

As a leader, Dr. Flynn co-founded and served as the Medical Director of the Autologous Bone Marrow and Stem Cell Transplant program at Abbott Northwestern Hospital and served as Director of the Virginia Piper Cancer Institute.

Finally, as an educator, he is a Clinical Professor at the University of Minnesota; a highly sought-after speaker — locally and nationally; provides medical education to residents at Abbott Northwestern, co-chairs the annual hematology oncology review course and is well-published with nearly 100 peerreviewed publications.

The Journal of the Twin Cities Medical Society

In presenting the award, Andrew Thomas, M.D., Twin Cities Medical Society Foundation Board member stated, “Dr. Flynn truly embodies the criteria of the Charles Bolles Bolles-Rogers award as a researcher, leader, teacher and an outstanding physician. The Twin Cities Medical Society Foundation is honored to award Dr. Patrick J. Flynn, the Charles Bolles Bolles-Rogers Award.”

Dr. Frederick Bolles Rogers, Trauma Program Medical Director, Lancaster General Hospital, Lancaster, PA and grandson of the late Mr. Charles Bolles Bolles-Rogers, participated in this award presentation, which was held on Wednesday, November 2, 2016.

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In Memoriam H. MEAD CAVERT, M.D., a member of the medical society since 1965, Dr. Cavert passed away on November 4, 2016. He was a former Professor of Physiology and Associate Dean of the University of Minnesota Medical School; and a founder of the Minnesota Medical Foundation.

FRANK J. INDIHAR, M.D., passed away on October 23, 2016. Dr. Indihar was an active member of the medical society, serving as the President of Ramsey County Medical Society in 1991, and in the MMA where he chaired the Minnesota delegation to the American Medical

CAREER OPPORTUNITIES

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January/February 2017

Senior Physicians Association A winter meeting of the Senior Physicians Association has been scheduled for:

Association. Dr. Indihar became a member in 1983.

Tuesday, February 21, 2017 11:30 – Social 12 Noon – Lunch 12:30 – Presentation Broadway Ridge Building\3001 Broadway Street NE, Mpls. MN

FLORA M. MACCAFFERTY, M.D., an obstetrician/gynecologist originally from Scotland, passed away on October 8, 2016. Most recently Dr. MacCafferty was active with the TCMS Senior Physicians Association serving on its Executive Committee and as President.

She joined the medical society in 1998.

“Understanding Aid in Dying” Rebecca Thoman, M.D. Compassion & Choices MN

A. BRUCE SUNDBERG, M.D., an orthopedic surgeon for 30 years, passed away on October 17, 2016. Dr. Sundberg joined the medical society in 1958.

Registration will open early February.

Questions? Contact Nancy Bauer at (612) 623-2893; nbauer@metrodoctors.com.

See Additional Career Opportunities on page 31.

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The Journal of the Twin Cities Medical Society

CAREER OPPORTUNITIES

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January/February 2017

31

LUMINARY of Twin Cities Medicine

By Marvin S. Segal, M.D.

JAMES J. JORDAN, M.D. In the late 19th century, Jean-Martin Charcot was instrumental in the splitting of the specialty now known as psychiatry from the field of neurology — and thus perhaps from mainstream medicine.

How does our Luminary feel about that?

Dr. James Jordan received both his B.S. and M.D. degrees from Loyola University/Strich Loyola Medical School and completed a mixed medicine internship at Chicago’s Michael Reese Hospital. It was during that educational time frame that he met and married his wife of over 50 years, Mary Ellen, a marriage that has been blessed with five successful children.

His Mayo Clinic residency was interrupted by a Navy stint during the Vietnam war, though he returned to Rochester to finish before embarking on a postgraduate experience at the renowned Tavistock Institute in London. He then moved to the Twin Cities — the site of his entire future professional career — becoming the Medical Director of the Adolescent Unit at St. Mary’s Hospital, followed by the Executive Medical Directorship of the Hamm Memorial Psychiatric Clinic, a position he held for 25 years.

The high esteem in which his psychiatric colleagues and the medical profession in general have held Dr. Jordan has been aptly demonstrated by the honors and positions of leadership responsibility he has achieved and assumed through the years: Distinguished Life Fellowship of the American Psychiatric Association; Teacher of the Year at our U of M Medical School; “First a Physician” award of our TCMS; advisory consultancies of the Minnesota State Council on Mental Health, the Minnesota Board of Medical Practice and the University of St. Thomas Health Care MBA program; Vice Chair of our TCMS Foundation; President of the Minnesota Psychiatric Association and of the Ramsey Medical Society where he devoted his year as President to addressing mental health issues.

The topics of Jim’s many clinical presentations demonstrate the gamut of his professional expertise — ranging from substance abuse to psychodynamic treatment. He currently is co-producing meaningful Public Television videos on “Understanding Depression and Suicide.” Applying analytics in assessing the success of remission in mental illness treatment has been among the most gratifying of his many professional endeavors.

Dr. Jordan’s beliefs and the conduct of his practice have a historical perspective with a practical approach born of decades 32

January/February 2017

in both realistic experience plus crisp, wise and earnest thought.

Of adolescent care he states, “Kids taught me a lot; taking the time to know them is really important; they are particularly susceptible to influences — both good and bad, and dealing with their defiance in a sensitive and loving fashion goes a long way toward positively effecting outcomes in adulthood.”

Of current trends in psychiatry, which seem to deemphasize direct face-to-face therapy in favor of increasing reliance upon pharmacotherapy, he states, “Yes, our specialty’s therapeutic approaches have been turned upside down . . . the truly successful treatment must utilize the best combination of both.”

Jim has shared and imparted his knowledge with countless mental health professionals as a U of M Clinical Professor via downtown St. Paul’s Hamm Clinic that recently established an endowment for a perpetual psychiatric fellowship in his name to honor his retirement.

Regarding the question raised about the separation of psychiatry from mainstream medicine, we can only reach a conclusion pertaining specifically to Dr. Jordan (which we can only hope is applicable for many others). The good doctor states, “I guess it’s just in my DNA to think of both entities as one — that concept has been emphasized in my training; I use it in my practice and teaching; it is critical to our successes.” Our Luminary, Jim Jordan, is both an outstanding physician and a superb psychiatrist — two accomplished attributes which go hand-in-hand . . . a wonderful example of why they cannot and should not be separated.

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine.

Please forward names of physicians you would like considered for this recognition to Nancy Bauer, Managing Editor, nbauer@metrodoctors.com.

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